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Friday, September 5, 2008

Childbearing in Surgical Residency

My intent was not to make such a serious posting, but I did not succeed.

After 8 years of surgical residency and fellowship, I am happy to report that our lives are returning to some sort of “relative normalcy.” Stress the word “relative” as most would not describe it anything close to “normal.” Life as a junior staff surgeon involves frequent call, occasional emergencies, and the ability to pick up slack for my senior partners. But my life now carries with it innumerably greater amounts of flexibility than life as a resident or fellow.

I now have a small teaching group of 2 female medical students in their first year of medical school. They “shadow” me in clinic or the operating room once a week. Although both are interested in what I do as a surgeon, inevitably they are most curious about my decisions and experiences with childbearing and family life. I tell them about training. I tell them that it is hard but that family life and motherhood are great and well worth it.

It was harder than what I tell them, especially as most of my training was before 80-hours and “80-hours” is often still theoretical in surgical training. All medical training is difficult, but surgical training is perhaps the hardest. Finding the balance between family life and work duties is hard for all surgeons, particularly for women surgeons in training.

The “ethos” of surgery remains principally masculine and rigid. Surgeons are supposed to be particularly strong, not to complain, and to go along with the “status quo”. While this may sound backward and negative, paradoxically in many circumstances I find the first two of these qualities admirable, and I still believe surgery to be one of the most exciting and rewarding career paths that anyone could choose.

As most parents will testify, childbearing is one of the less challenging aspects of parenting. But decisions around childbearing and the time with your newborn are important shaping experiences.

The concept or image of a pregnant surgeon, whether or not in training, is still a foreign one to quite a number of surgeons, some of whom feel free to share their opinions. The decision and process of pregnancy for women residents (I suspect in a number of medical fields) produces anxiety and (both subtle and overt) comments. I have seen female residents leave surgical residency either for another medical specialty or leave medicine entirely as a result of issues surrounding childbearing. Two of my female resident colleagues “decided” to return to work only a few weeks after giving birth because one had been placed on bedrest before giving birth and the other was told two weeks was all the residency program could bear. Female residents that take full time for maternity leave often “owe” additional months (as it might be in other training programs) but also often suffer palpable resentment from fellow residents.

This is, in part, because typically the decision for a female surgical resident to have a child directly impacts the entire training system. And surgery, worse than most other medical sub-specialties, has not found solutions to address these issues. Most surgical training programs suffer from more limited people-power. When one person is not performing optimally or is absent for any reason, the entire team feels it. The call schedule might change from every 3rd night to every 2nd (of course, illegal under current regulations). This issue is perhaps the worst in some of the sub-specialties where the entire training program is composed of a handful of individuals. Interestingly, several of my female friends who have entered small private practices after training also experience similar pressures as childbearing would impact their partners' lives significantly.

Issues of maternity leave, parental leave, and time for other parenting duties in most residency training programs have not been traditionally prioritized. Not surprisingly, fields like surgery which have been slowest to find solutions and to transform their ethos feel much-needed pressure to start making changes -- as women now make up over half of graduating medical school students nationwide.

Personally, I “timed it” well, having my daughter during my years in research during residency. My 4-year-old daughter is beautiful, well-adjusted, and a great kid. And my husband and I have found a satisfactory parenting balance that works. I am extremely lucky, but I would like for my experience to be less of the exception.

We had similar problems when I was in psychiatry residency (and again when I was a pregnant ward chief). The obvious solution for house staff is to have PAs or NPs who can take on intern level responsibility when residents go on leave. Burdening others already stretched to the limit is a lousy alternative, and one that creates a very toxic emotional and physical environment for everyone. I wonder if the number of residents who need to go on bedrest pre partum is actually related to this stress. More rational planning might in the long run reduce the impact of resident pregnancies. Staff are currently paid from a different pot than residents, which makes this a hard solution to implement, but it seems feasible and sensible to me.

There is another issue here as well. Post partum women often have mild cognitive impairment. (A friend once said it was like having your brain removed, kicked a few times, and reinserted rotated forty five degrees). The research on this has been inconclusive, but to my mind not well designed, in fact, another example of science dismissing what women know about themselves (though perhaps motivated by a misplaced desire not to pathologize women's normal experience.)

The point is that it is or borders on being educational malpractice to encourage or insist that a woman return to training before she is fit for duty. I have had a couple of good medical students fail exams because they did this, and the consequences for house staff are worse. A mentally cloudy physician is far more likely to make medical errors. We should not ignore a potential source of physician impairment--not to use this against mothers, but to lobby for a system that does not set arbitrary time boundaries for maternity leave, instead basing length of leave at least in part on the returning trainee's ability to fulfill the requirements of a responsible job.

Reading these commments and being a surgical resident myself (who would like to have children), I would like to add a different perspective. The idea (as juliaink suggests) that physician extenders can solve this issue does not take into account the complexities of surgical training and surgical care. While a good physician extender could cover an intern or 2nd year trainee, they should not run traumas or manage many other emergency situations that occur in surgical care (i.e. starting a case to stabilize a patient when no one else is there, emergency cricothyroidotomy or emergency thoracotomy (post-op or in trauma)). As a 4th year resident at a community program (one of 2 women) who has had to do all of the above, I still mostly take 1 in 3 nights of call in the hospital with a junior resident. For these very reasons, I feel like I will have to forego motherhood at least until my training is finished.

As a PGY-3 surgery resident in a large (9 categorical), yet over-extended program having serious problems adhering to the 80-hr work week rules, I'm terrified of what could happen if I get pregnant. A female resident in my program hasn't gotten pregnant in over 8 years, and of the two that did, one quit surgery.I've been in the lab for the last year and am slated to return to residency as a PGY-4 in June. I'm not pregant yet, but trying. Unfortunetly for me, nature had its own ideas of when I would get pregnant, so I haven't gotten pregnant "in-time" while I'm in the lab, and so if I get pregnant now I'll be returning VERY pregnant and likely delivering shortly after I return (that's IF I get pregnant soon). Is it irresponsible for me to keep tyring? Is it selfish, knowing that I'd be returning maybe 8 months pregnant? Do I take another year out and delay graduating and fellowship? Should I have to?I'll be honest, I'm just going for it. I may regret it when I'm a 4th year resident who hasn't operated in 2 years running traumas at 8 months pregnant, then only taking 2-4 wks maternity leave and dealing with an infant in this crazy new-Mom state, but I can't put off my life! I'm 32 years old and have atleast 4 more years of training (planning on a Vascular fellowship). Should I give up family for my career? Or the other way around? No. My program is going to flip out if/when I get pregnant. And my response to that- they're going to have to just deal with it.Female surgery residents should not have to choose between family and career. Male residents don't have to. The field needs to figure out a way to make it work. I may piss off my co-residents, my Program Director, and my Chairman, but I don't care. It's going to be the hardest thing I'll ever take on, but I want a family. I want a baby, and I'll make it work. And when IS the right time as a woman in surgery? Other than the lab (b/c that didn't work out for me). As a Chief resident (yikes). As a vascular fellow, when I'm in the endo suite all day exposed to radiation? As a new staff somewhere, trying to start a career? There's no good time. So why not now?But I can't help feeling really scared, and that I WILL care that I've pissed off my entire program, and that my career AND family will suffer for my 'trying to do it all'. I feel like I'm on the edge of a new frontier for my program. And it's daunting.

More than 50% of the students at my medical school are women. Most of them plan on becoming mothers.

Pretending that doctors aren't going to be parents isn't working. This attitude is prevalent through all of the working world. I suffered negativity both time I had children while working (once in retail and once as a researcher). Both times I was denied my maternity pay in a vindictive way, among other issues.

But, in a residency or fellowship program, there are even more layers of problems, obviously, from the patients to peers. But, anyone who understands physiology would realize that the years most women would be in those training situations are the prime reproductive years.

Ok. So I am pregnant and in training after practicing for a while. My boss knows, but the rest of the team does not (I am not showing yet).I am due after I finish my training so my issues are more financial and how to look for a job with a big belly. Also any leave I take it will be just detrimental to me, since I will not be making any money.I look around the group of surgeons and trainees (100% male) and I feel like I am doing something against that whole environment..I try to keep in my mind that in order to society to continue, women have to have babies. It is not like we are choosing to take a vacation for months or something.As for the programs I do believe they should hire locum tenans people to cover for that period of time. For guys may sound unfair, but their mothers and wives were pregnant one day.I use to be amazed by the residents that only took a month or two off, but now I am contemplating just taking a month off because I cannot afford to take more.I think a lot of the negative thoughts are in our mind and we just have to shake them off.As for the right time, I still think its best in training because you have a system of coverage. In practice you will book cases and not know if you will be well enough to finish it.I had to scrub out twice in 3 months , but I was assisting a surgeon so I just asked the scrub nurse to help out and came right back.I guess is also improtant to keep in mind that all these people around us will go away from our lives at some point, but your baby will be with you for a long time and if something goes wrong, it will be hard to forgive yourself if you think you havent done what was right for your kid.As my husband says, we are not in control afterall. At some point we have to give it up to the Boss- God.

Hi! I am not yet in college, but i really would love to be a surgeon. I also really want to have a family.... from your view point,do you think it's possible to have a family and still have a semi "normal" life, and still be a surgeon?

Mothers in Medicine is a group blog by physician-mothers, writing about the unique challenges and joys of tending to two distinct patient populations, both of whom can be quite demanding. We are on call every. single. day.

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